A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

Healthy weight

Malnutrition

Overweight

Obesity

Answer and Explanation

The Correct Answer is A

A. A BMI of 20 falls within the healthy weight range for adults.

B. Malnutrition is characterized by a BMI below the healthy weight range and is typically associated with BMI values less than 18.5.

C. Overweight is characterized by a BMI between 25 and 29.9.

D. Obesity is characterized by a BMI of 30 or higher.

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Correct Answer is D

Explanation

A. Diminished bowel sounds are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.

B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.

C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.

D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.

A. Insert an indwelling catheter if the client has not voided in 3 hr. B. Obtain the abdominal girth now and every 4 hr. C. Assess and document the level of consciousness every hour. D. Measure the amount of gastric drainage every 2 hr. E. None F. None

Correct Answer is A

Explanation

A. Inserting an indwelling urinary catheter is within the scope of practice of an LPN and is an appropriate task to delegate.
B. Measuring abdominal girth involves assessment of ascites progression, which requires the nurse’s judgment and should not be delegated.
C. Assessing and documenting the client’s level of consciousness requires critical nursing judgment and must be performed by the RN.
D. Measuring gastric drainage every 2 hr is an appropriate task for an AP, not specifically requiring an LPN.

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A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload?

Correct Answer is D

Explanation

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

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